Evaluating a Global Payment Methodology in Integrated Primary Care

1. Session # G5A October 17, 2015 Evaluating a Global Payment Methodology in Integrated Primary Care Shandra M. Brown Levey, PhD, Department of Family Medicine, University of Colorado School of Medicine Emma C. Gilchrist, MPH, Eugene S. Farley, Jr. Health Policy Center, University of Colorado Denver; Kaile Ross, MA, Eugene S. Farley, Jr. Health Policy Center, University of Colorado Denver; Polly Kurtz, MBA, Collaborative Family Healthcare Association; Benjamin F. Miller, PsyD, Eugene S. Farley, Jr. Health Policy Center, University of Colorado Denver Collaborative Family Healthcare Association 17thAnnual Conference October 15-17, 2015 Portland, Oregon U.S.A.

2. Faculty Disclosure The presenters of this session • have NOT had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Discuss a global payment model for healthcare and its impact on clinical practice. • Describe a mixed method evaluation used to determine if a global payment method can financially support and sustain behavioral health in primary care. • Identify key components, measures, and lessons learned when working to implement, support, and evaluate innovative payment methodologies.

4. Bibliography / Reference Kathol RG, deGruy F, Rollman, BL. Value-based financially sustainable behavioral health components in patient-centered medical homes. Annals of Family Medicine. 2014 Mar-Apr; 12(2) 172-5. Kathol RG, Butler M, McAlpine DD, Kane RL. Barriers to physical and mental condition integrated service delivery. Psychosomatic Medicine. 2010; 72:511-518. Katon W, Russo J, Lin EH, et al. Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. Archives of general psychiatry. 2012;69(5):506-514. Landon BE. Keeping score under a global payment system. New England Journal of Medicine. 2012; 366:393-395. Lake TK, Rich EC, Valenzano CS, Maxfield MM. (2013) Paying more wisely: effects of payment reforms on evidence-based clinical decision-making. Journal of Comparative Effectiveness Research 2, 249-259.

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Overview • In this presentation, we will: • discuss a project intended to evaluate if a global payment method can financially support and sustain behavioral health in primary care, • describe how different payment models may affect clinical models of integration, • and present real world applications of a global payment methodology in primary care practices. • Through a description of our mixed methods evaluation approach, we will: • share how we worked to better understand clinical, claims, and interview data and how this is being used to help inform policy.

7. Three Year Project with CFHA, DFM, and RMHP • Project launched in July 2012 • Year 1: Identified 3 control and 3 intervention practices • 18 Month Study Period (Mixed method evaluation) • 6 Months – Wrap-Up and Conclusions

8. Methods • Data Collection • qualitative & quantitative data over 18 months. • Data Management • Analysis with a multidisciplinary team

9. Clinical Data Methods Step 1 – Identify the Aggregated Cohort Step 2 – Develop the Specifications for the EMR Data Extraction Step 3 – Develop the Specification for Extraction of Behavioral Health Data Step 4 – Extract Clinical and Behavioral Health Data Step 5 – Merge Clinical EMR Data with Longitudinal HIE Data Step 6 – De-identify all Data Step 7 – Provide RMHP Claims Data for SHAPE Study Member

10. Sunrise Mountain Family MidValley Foresight Primary Care Partners Axis

11. Quantitative Results

12. Qualitative Results • Purpose of the qualitative data • Monthly Phone Calls – support • Interviews – to tell the story of the practice • Site Visits – support and insight to daily practice • Lessons learned: qualitative questions to assess impact of payment structure

13. Payment • Payment is conceptually difficult to understand • Global payment strategy in a FFS world • Global payment methodology and relationship to clinical practice • Change in clinical practice/leadership/SHAPE benefits/integrated care delivery • Not a fix all

14. Payment “We are so thankful that we had this opportunity. I don’t think we would have been able to do it, just with CPC…I don't know how some of the practices are doing Integrated Behavioral Health and trying to fund it through their CPC Payments. I'm sure they are having to rob Peter to pay Paul a bit. We've had sort of the best of both worlds here… the opportunity to do both SHAPE and CPC. Because it has given us just enough funding that we don't have to worry about it. The doctors are not sitting in meetings going how are we going to pay for that? How are we going to pay for this?” “I: So can you tell us about what you know about the financing for behavioral health? R: I don't know anything…. I'm just being honest and I don't want to say anything that I don't know.”

15. Leadership Throughout the course of SHAPE, teams gained a better understanding of what it takes to deliver team based care New leadership roles emerged Support for partnerships reflected commitment to their community needs

16. Leadership “I think we have become more open and understand the value of team based care. I think at first, we maybe didn't quite understand. Ok, what is the physician's role in the team? Now we understand how much people outside of us, have to offer patients. So I think we have seen this sort of philosophical change away from the physicians as the key element of the practice. So really the team is the key element of the practice.” - MD

17. Roles There are a variety of clinical and administrative roles that interact to support and facilitate needed patient connections Interaction with BHP and sense of personal responsibility for facilitating connection to BH seemed to increase from baseline to f/u BHPs began initiating QI projects to increase routine screening (i.e. depression and alcohol) in order to reach more patients in need

18. Roles “My role is I identify the patients who need a stress questionnaire which is the PHQ, anxiety screening, and the alcohol AUDIT. And we typically do those on patients once a year. And if they get their stress questionnaire, then we score them. And if they are positive- 10 or higher on both - PHQ and the GAD, a positive alcohol, then we alert [BHP] that this is somebody she maybe needs to do a warm handoff, or maybe she can talk to before the Dr. gets to them. And then on her recommendation, we re-screen them at a later date.” – Front Desk Staff

19. Provider and Staff Experiences PCP and staff felt more supported and able to provide good care with a BHP on board PCPs appreciated BHP help when they had patients in crisis Having BHP around gave PCPs more peace of mind and lessened workload

20. Provider and Staff Experiences • After experiencing integrated care, practices can’t imagine working without it • "So I've had several patients where after their or during their visits, that will have Integrated Care come in, right then and there. And it is so nice to have the patient education part going on. Because a lot of times our teams are busy providing the essential health care on my side. So when we call Integrated Care in, they will provide teaching and the patient then, all of a sudden, like I've seen like a light bulb go off..... And you may have told that patient the same exact thing, but somehow when Integrated Care presents it, they understand." - Office Manager

21. Provider and Staff Experiences • Personal benefits to having BHP on site: • “To tell you the truth, I learned about it too. And I take advantage of it. I mean I take my daughters too. I mean things that I can't help them up, I've taken them to therapy and I have a 14 year old and a 9 year old, and it's helped me a lot. And because of my experience, I can let other people know and they don't feel judged or oh my gosh, you have the same issues I do." - MA

22. Patient Experiences Stories of success at each site “Some people just don't get the concept. What is Behavioral Health? I had a situation the other day. Mom had her 15 year old son who is overweight and has high blood pressure issues. I called to get her son's schedule to see the psychologist. And she freaked out: ‘Why? What's going on with my son?’ And I say: ‘No, no. It is just to make him understand that his life style is costing him so many medical problems. [The psychologist] is just going to help him understand that and set some goals with him, so he can change some behaviors, and change his medical problems.’ After I explained, she was very happy about it. She said, ‘Yeah,he needs to understand that what he’s doing is not good for his health and he needs to change that.’ So she was very pleased.” – Front Desk Staff

23. Sustainability “I am worried about the sustainability of all of it… We are trying to find out more ways we can bill things, like the screenings. But we are finding not every carrier is going to pay those. There are some codes that Medicare and Medicaid are coming up with and we can get some recoupment on the time spent with those patients… But we are committed to integrated care and we've definitely seen the benefit of it. So, we are going to make sure it works in our practice, somehow.” – Practice Manager

24. Sustainability “I hope we can sustain it indefinitely. I see it as a real valuable tool. Patients kind of go What? At first. But then once they are used to it, they find it so valuable. So I see it as a valuable asset to our medical practice. I hope it can continue to be funded. It is very good. And we are getting so many new patients that are so needy for this.” – MA

25. So What? Now more than ever people are looking for real world payment reform solutions This methodology can be scaled regardless of setting Infrastructure and data management are essential Multi-level change requires multi-level strategies Don’t wait; move now

26. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!